Tag Archives: Injection Drug Users

Food and Drug Administration Pulls Opana ER from Shelves

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

In April 2016, HEAL Blog wrote an entry about the fascinating and heartbreaking first episode of National Public Radio’s (NPR) series, Embedded. Host Kelly McEvers found a group of prescription opioid Injection Drug Users (IDUs) who allowed her to record an audio interview about their lives and how they use their drugs. The drug in question was Endo Pharmaceuticals’ powerful prescription opioid, Opana ER (McEvers, 2016). A little over a year after this broadcast, the Food and Drug Administration (FDA) reached the conclusion that the “…benefits of the drug may no longer outweigh the risks,” and have asked Endo to remove Opana ER from the market (Mandal, 2017).

What’s at stake here isn’t just a 4% increase in prescription opioid overdose deaths in 2016 (n=17,536), nor the 23% increase in heroin-related deaths (n=12,989); it’s not even the 73% increase in synthetic opioid-related deaths (n=9,580) (Stobbe, 2016). What’s at stake, at least for Endo Pharmaceuticals, is the $158 million in sales Opana ER brought in for Endo in 2016 – a 10% decrease from 2015 (Mandal). For Endo, pulling one of their most successful products from the market means a huge hit to their bottom line.

Opana ER pill bottle

Photo Source: Medcitynews.com

Opana ER, first introduced by Endo in 2006, was reformulated in 2012, when the manufacturers began adding a plastic coating to the outside of the pill to make it “abuse deterrent.” This move, while initially praised by the FDA and lawmakers as a great step forward to combating prescription drug abuse and addiction, simply shifted how drug users abused the drug. While the initial formulation could be crushed and easily snorted nasally, the plastic coating prevented this practice. Necessity (read: addiction) being the mother of invention, drug users found a way to abuse the drug by melting the plastic coating off, filtering the coating out through mesh, load the liquefied drug into a syringe, and injecting it straight into their bloodstreams. The McEvers Embedded piece literally goes over a step-by-step “How To” guide that is already known by IDUs.

The bottom line for states, counties, and municipalities who are having to cope with the 40,105 opioid drug-related deaths in 2016 comes down to more than just money – the issue is negatively impacting virtually every arena of daily life. Families are rent asunder, children are left orphaned, and emergency personnel are facing their own increased risk of overdose from inhaling or coming into direct contact with the powerful synthetic opioids, fentanyl and carfentanil, during overdose calls and drug busts. The risk of overdose due to exposure is so great that the Drug Enforcement Agency just this month issued a safety guide for first responders who might come into contact (Chanen, 2017).

Pain advocates who have long pushed for easy access to prescription painkillers argue that increasing restrictions places an undue burden upon patients who properly adhere to treatment regimens, using powerful prescription opioids as prescribed. To their way of thinking, regulations and prescribing limits unfairly limits the ability of those who live with chronic pain to function and/or go about their daily lives. Pain advocacy groups (many of which are conveniently funded by the very pharmaceutical companies whose drugs are at risk) have repeatedly, and in many cases successfully, lobbied state and Federal legislators to prevent the passage of any legislation that might hinder their access to these drugs.

I don’t buy it, and apparently, neither does the FDA. Endo Pharmaceuticals have said they’re “…evaluating the options and reviewing the situation to opt for an appropriate path forward.” Should the company refuse to remove the product voluntarily (as the FDA has asked), the agency intends to take steps to formally require its removal by withdrawing approval (Kean, 2017).

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Generational Stigmata and HCV

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

When it comes to Hepatitis C (HCV), people in America have long assumed that it was (and is) a Baby Boomer problem. Recent statistics, however, indicate that a rapidly increasing number of new HCV diagnoses are linked to Injection Drug Use (IDU), and that IDUs will likely lead to an exponential explosion of new infections compared to previous years. With that reporting, however, a stigma has arisen amongst the Baby Boomer population (the Birth Cohort), leading some in the cohort to avoid screening for the disease. Research published in March 2016 (Joy, 2016), however, indicates that HCV infections within the Birth Cohort is much more likely to have arisen from unsafe medical practices on behalf of doctors and hospitals, rather than any lifestyle choices made on the part of patients.

The research, published in The Lancet Infectious Diseases journal, was conducted by scouring over 45,000 documents and records, examining 45,316 sequences of HCV Genotype 1a – the most common strain – and then used a technique called “phylogentic analysis” to focus on five HCV genes and trace the dynamics of the HCV epidemic. The results suggest that the initial peak of the HCV epidemic – the time when initial infection and introduction of the disease in the Birth Cohort – occurred between 1948 and 1963, far earlier than many had suggested.

These infections are most likely related to the techniques and equipment that medical professionals used in the post-World War II (WWII) era, prior to the establishment of safer technologies, equipment, blood screening, and techniques that came about in the wake of the initial HIV crisis of the 1980s and 1990s. Strict blood screening techniques were not, in fact, common place until the U.S. government mandated the practice in 1992. As such, anyone who received a blood transfusion or underwent invasive medical procedures prior to that year may have been exposed to HCV, and should be screened for the virus.

Stigmata are nothing new, however, for the Birth Cohort. This is a group who helped to push the sexual revolution and drug use of the 1960s and 70s, and began having children in the 1980s. During this time, reports of sexually transmitted diseases and viruses, as well as transmission via IDU, began gaining more media exposure, both of which gained a level of ignominy in the 1980s in relation to HIV. We must remember that many media reports indicated that HIV only impacted those in the “4 ‘H’ Club” – Heroin users, Hookers, Haitians, and Homosexuals. When this type of branding in the media and in government conversations occurs, stigmata arise that leads to people avoiding testing and treatment.

Since that time, however, infectious diseases have undergone something of facelift, with multi-million-dollar ad campaigns and outreach programs on the part of pharmaceutical companies and governments trying to spread the word about getting tested. These efforts are part of a concerted effort to reduce the stigma associated with chronic illnesses and infectious diseases that are both costly to treat and incredibly harmful to those living with them if they go untreated.

For the Birth Cohort, however, to feel as if they should be lumped in with what many view as an unsavory crowd simply goes counter to the reality of the epidemic. Screening for HCV isn’t just something that applies to those who practice risky behavioral patterns; rather, it should be something that is routine within the Birth Cohort, so that they can cure HCV and live their waning years without the concern of HCV-related illnesses and co-morbidities.

References:

  • Joy, J., McCloskey, R., Nguyen, T., Liang, R., Khudyakov, Y., & Olmstead, A., et al. (2016, March 30). The spread of hepatitis C virus genotype 1a in North America: a retrospective phylogenetic study. The Lancet Infectious Diseases16(6), 698-702. doi:10.1016/s1473-3099(16)00124-9. Retrieved from: http://dx.doi.org/10.1016/S1473-3099(16)00124-9

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Hepatic in the Heartland

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

The Iowa Department of Public Health (IDPH) issued, this month, the state’s most recent epidemiological profile for Hepatitis C (HCV), and that profile isn’t looking good for people under the age of 30. Between 2010 and 2015, people between the ages of 18-30 have seen a 300% increase in new HCV infections (IDPH, 2017a). New HCV infections amongst all ages saw a 48.70% increase over that same period.

For nearly thirty years, the conventional wisdom has been that HCV is a Baby Boomer disease, and that, outside of the occasional People Who Inject Drugs (PWIDs), there is really no need to screen other groups for infection. What that preconceived notion failed to account for was a resurgence in popularity of heroin as the drug of choice and the resultant increase in Injection Drug Use (IDU). Moreover, the setting of heroin use has largely shifted away from being an urban problem that impacts mostly minority communities to one that’s plaguing suburban and rural areas where access to comprehensive healthcare and recovery services lags behind the more urban settings with which the heroin addiction has historically been associated.

The IDPH report indicates that IDU accounts for 68% of all new HCV infections, and that 55% of Iowans living with HCV live in one of six counties: Polk, Linn, Scott, Woodbury, Pottawattamie, and Black Hawk. Though these counties are among the most populous in Iowa, the state is, itself, relatively rural in comparison to its neighbors. In the IDPH HCV Fact Sheets, the increase in new infections amongst younger Iowans is specifically tied to IDU, indicating that ER visits for opioid and heroin overdoses increased 253% and 2,500%, respectively (IDPH, 2017b).

Randy Mayer, Chief of the IDPH Bureau of HIV, STD, and Hepatitis puts a positive spin on the report:

“These data indicate that Iowans are getting tested and referred to treatment by their medical providers. Everyone born between 1945 and 1965 and anyone who has ever injected non-prescription drugs, even once, should be tested for hepatitis C (Bunge, 2017).”

This is the first report by the IDPH to look at incidences of HCV in Iowa, and Mayer adds that, while this is the first attempt to pull together various data from around the state, the IDPH has been watching similar reports out of Appalachia, and as such paid additional attention to people under 30 (Shotwell, 2017).

This inaugural report from the IDPH does a lot of things “right,” my personal favorite being the use of APA citation, rather than MLA, allowing for in-text citations, rather than footnotes. Writing stylistic approach aside, the report does a fantastic job of indicating which areas Iowan medical professionals need to watch and where interventions most need to be made, as well as indicating that follow-up after treatment is necessary to avoid re-infection.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Heroin and Hepatitis Go Hand in Hand

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

Over the past year, HEAL Blog has paid a lot of attention to heroin, particularly in relation to the massive increase in heroin and prescription opioid overdoses in Appalachia, the Midwest, and the Northeast. While the purpose of HEAL – “HEAL” standing for “Hepatitis: Education, Advocacy, and Leadership” – is to specifically address issues related to Viral Hepatitis, and particularly Hepatitis C (HCV), when we cover issues related to prescription opioid abuse and heroin, we sometimes fail to connect the dots between the two topics. There is, in fact, a very high correlation between Injection Drug Use (IDU), People Who Inject Drugs (PWIDs), and the transmission of HCV: most new HCV infections in the three previously listed regions are related to IDU.

Sources of Infection for Persons with Hepatitis C

Photo Source: Pinterest

HCV and HCV-related co-morbidities (e.g. – Cirrhosis, Advanced Liver Disease) kill more Americans each year than any other infectious disease (Centers for Disease Control and Prevention, 2016). It is also one of the most expensive diseases to treat, with Direct Acting Agent (DAA) drug Wholesale Acquisition Costs (WACs) ranging between $50,000 and $100,000 for twelve weeks of treatment. This makes preventing the spread of HCV not only a matter of physical health, but one of fiscal health.

Despite pharmaceutical manufacturers’ arguments that the one-time cost of a regimen to achieve a Sustained Virologic Response (SVR – “cure”) is far cheaper than the long-term costs of other diseases, not to mention the long-term costs that arise if HCV goes untreated, state and Federal healthcare budget departments remain unconvinced. Budgeting processes generally focus on a single year, rather than accounting for multi-year spending, so arguing that long-term expenditures “cost” more hasn’t been an effective argument. Even with the clandestine pricing agreements and rebates – clandestine, because they are not made public due to “trade secrets” laws – states have yet to begin treating every HCV-infected client on their government-funded rosters. To do so would blow through entire pharmacy budgets several times over, in many states.

With PWIDs representing the highest number of new HCV infections between the ages of 18-35, state legislatures are starting to come around to the realization that the best way to avoid spending that money on expensive treatments is to put into place Harm Reduction measures that are shown to prevent the spread of blood borne illnesses. As it is very difficult and unfeasible to stop IDU, syringe exchanges can be put into place that allow PWIDs to inject using clean needles, rather than sharing them.

Syringe exchanges have, for much of the past forty years, been largely reviled by politically conservative politicians and states; many Republican politicians have repeatedly argued that state-sponsored syringe exchanges will only encourage bad behavior, serving as a tacit endorsement of IDU. Now that prescription opioid and heroin abuse has moved outside of the urban areas and into the suburban and rural areas that serve as bastions of the Conservative ideal, suddenly, these politicians are coming around to the idea.

Medical technician counting needles.

Photo Source: Daily Beast

In the past two years, several considerably conservative states have passed laws allowing syringe exchanges to be established – Indiana, North Carolina, Ohio, and Virginia, to name a few – largely in response to a relative explosion of new HIV and HCV infections related to IDU. The problems that politicians and their constituents once relegated to the big cities have come to their quiet towns, and have done so right under their noses. The lessons out of Scott County, Indiana, where nearly 200 people tested positive for HIV near the end of 2015 and into 2016, are still reverberating throughout the region, and people are starting to look at ways to prevent the spread of disease, rather than punish the behavior.

It is clear that the opioid and heroin abuse epidemic is not going away, anytime soon. Since we aren’t likely to stop currently addicted people from injecting drugs, the smartest path forward is to at least make certain they can do so safely.

References:

  • Centers for Disease Control and Prevention (CDC). (2016, May 04). Hepatitis C Kills More Americans than Any Other Infectious Disease. Atlanta, GA: Centers for Disease Control and Prevention: Newsroom Home: Press Materials: CDC Newsroom Releases. Retrieved from: https://www.cdc.gov/media/releases/2016/p0504-hepc-mortality.html

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

 

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Widening HCV Epidemic in Wisconsin

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

The state of Wisconsin has a Hepatitis C (HCV) problem; one that’s not going away, and is no longer affecting only the Baby Boomer birth cohort. In 2006, 2,355 new cases of HCV were reported by the state; in 2013, that number rose 12% to 2,638; between 2013 and 2015, the number of new HCV infections rose 42% to 3,745 in a span of only two years (Wisconsin Department of Health Services (WI DHS), 2016b).

While the incidence (the number of new cases) seems relatively low, relative to the population, it is important to remember that these numbers represent only the confirmed cases of HCV infection. Health officials estimate that there are roughly 90,000 people living with HCV in Wisconsin, 75% of whom have no idea they’re infected (Madden, 2017).

Wisconsin Department of Health Services

Photo Source: State of Wisconsin

More troubling than just the massive two-year-increase in new infections is the relatively new trend of new HCV infections amongst people aged 15-29. In the past ten years, reports of HCV have shifted from a single peak of middle age adults in 2006, to a distribution of two peaks in 2015 (Wisconsin Department of Health Services, 2016a). While the increased rate of HCV among older adults is likely the result of a new recommendation to screen the birth cohort, the new peak in infection rates among 15-29-year-olds is likely due to the vast increase in the abuse of prescription opioids and heroin in rural and suburban areas. Between 2011 and 2015, the rate of HCV infection in 15-29-year-olds increased from 40.4 per 100,000 people (2011) to 86.9 per 100,000 people (2015) (WI DHS, 2016b).

Not far behind them are those aged 30-49, with a rate of 74.8 per 100,000 (2015), up from 57.9 per 100,000 (2011), again, largely due to the increase in Injection Drug Use (IDU). It is estimated that 50% of People Who Inject Drugs (PWIDs) become infected with HCV within five years of injecting (WI DHS 2016b). Strong prescription opioids have been readily available via legitimate prescriptions since the mid-1990s to treat virtually any type of pain, during which time, prescription abuse has become a major issue amongst children and teens who gain access and become addicted to these drugs through either their own pain-related legitimate prescriptions, or through illegally obtaining prescriptions written for family members or friends.

While the prescription opioid addiction crisis has been endured for over twenty years, now, only recently have drug manufacturers – such as Perdue Pharma, maker of OxyContin and Opana, the two most widely abused opioid drugs in the U.S. – been called to account for both the addictive nature of their drugs and the oftentimes extraneous supply of medications being routed through local and family-owned pharmacies that often lack the same level of scrutiny and oversight needed to effectively combat over-prescribing and abuse. Wisconsin also does not current require a physical exam for patients to be prescribed opioid painkillers, nor is ID required for all opioid prescription purchases (HIV/HCV Co-Infection Watch, 2017).

Wisconsin also has no doctor shopping laws on the books – laws preventing patients from seeking prescriptions from multiple physicians – which limits the state’s ability to crack down on patients who attempt to gain prescriptions from various sources, as well as prescribers who are lax in their monitoring of patient behaviors. In conjunction with the latter, Wisconsin physicians and pharmacists are not required by the state to undergo mandatory education regarding appropriate opioid prescribing practices in order to ensure that they do not over-prescribe, and that they are prescribing opioids only for medically necessary reasons (HIV/HCV Co-Infection Watch, 2017).

While Wisconsin is certainly not experiencing HCV infection rates as high as other Midwestern and Southern states, such as Indiana, Kentucky, Ohio, Tennessee, or West Virginia, this relatively sudden increase in rates and new infections is troubling. We, here at HEAL Blog, will continue to monitor the situation as it develops.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Rural Americans Still Lack Access to Syringe Exchange Programs

HEAL Blog is the recipient of the ADAP Advocacy Association’s 2015-2016 ADAP Social Media Campaign of the Year Award
By: Marcus J. Hopkins, Blogger

The HEAL Blog  covers the expansion of Syringe Exchange programs as an effective and proven method of Harm Reduction to prevent the spread of HIV and Hepatitis C (HCV). While there have been some notable successes over the past few years, especially in states where rural transmission of both HIV and HCV is increasing, the stark reality is that these areas largely lack access to the Syringe Exchange programs that could help to stanch the spread of deadly diseases that are easily spread through sharing and reusing needles.

A new report from the Centers for Disease Control and Prevention (CDC), decreases in HIV diagnoses in People Who Inject Drugs (PWIDs) indicate success in HIV prevention. However, emerging behavioral and demographic trends could reverse this success (Wejner, et al, 2016). In terms of demographics of PWIDs, both African-Americans and Hispanic populations have seen consistent and rapid downward trends in all three areas: HIV diagnoses among PWIDs, those who shared syringes to inject drugs, and people who reported injecting drugs for the first time. Whites, but urban and non-urban, however, did not fare well in these measures.

In both Urban and Non-Urban settings, new HIV diagnoses amongst white PWIDs saw a slight increase; the same is true of whites who shared syringes to inject drugs; whites made up over 50% of people who reporting injecting drugs for the first time. This shouldn’t come as a big shock to those who have been following drug usage trends – the abuse of opioid prescription drugs and heroin in rural and suburban areas has spiked significantly, over the past twenty years, as we have covered in previous posts – areas where the population tends to skew heavily to the White.

Sign reading, "HIV Needle Exchange"

Indiana Needle Exchange

While Syringe Exchange Programs (SEPs) have grown more common in urban areas, people living in largely rural states, rural areas, and suburban areas have again fared poorly in this regard. A 2015 report from the CDC surveyed 153 SEP directors (out of the then 204, in March 2014), and found that only 9% of SEPs were in Suburban areas and only 20% in Rural areas (Des Jarlais, et al., 2015). The areas hardest hit by the increase in PWIDs – the Northeast, South, and Midwest – had a total of 11 SEPs in Rural areas; the West, by comparison, had 18 in Rural areas. While this data is from 2013, and more SEPs have been opened, it is difficult to get a definitive count of the number of operative SEPs.

From a health emergency perspective, we have a White HIV crisis brewing in rural and suburban America. Beyond the issues related to PWIDs, there is also the increase risk of sexual transmission from PWIDs to those who do not inject drugs. Whites have consistently represented the largest number of new infections, since the beginning of the epidemic (not to be confused with the disproportionate rate of infection amongst minority groups), and for the first time in 2014, White PWIDs had more HIV diagnoses than any other racial or ethnic population in the country (Sun, 2016). State and Federal laws – especially in rural states – continue to present barriers to establishing and funding SEPs in areas that are the hardest hit.

One of the most frustrating aspects of reporting healthcare statistics is the reporting lag; the references used in this post present data that is at least two years old. This problem exists because of the time it takes for states to finalize data, in addition to the time it takes for peer reviewing before publication. While there were 204 operating SEPs in the U.S. in 2013/2014, it’s now 2016, and we could use some updated numbers.

References:

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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A Case of Northern Overexposure

By: Marcus J. Hopkins, Blogger

The face of Hepatitis C (HCV) continues to change, as the State of Alaska Section of Epidemiology is reporting – nay, warning – of yet another example of rapid increase in HCV rates among people aged 18-29 (State of Alaska, 2016). Of the 1,486 cases of HCV reported in 2015, the aforementioned age group represented 459 of those cases – roughly 31% – putting them on par with people aged 30-49 (461, roughly 31%). The remaining cases in 2015 were seen in people aged 50 or older.

This data conforms to national trends in HCV. While the majority of cases tend to occur within the 50+ age range, the fastest rate of increase continues to exist amongst the young, largely driven by opioid prescription drug and heroin abuse. Injection Drug Use (IDU) is consistently pegged as the largest driver of new infections, and the problem continues to grow and more people are being prescribed addictive prescription opioid drugs for pain management for injuries that may not necessitate them.

While opioid and heroin IDU is a growing problem, Alaska has long been utilizing Harm Reductions methods to attempt to mitigate the harm to IDUs. Four Syringe Exchange Programs (SEPs) are currently operating in Alaska in four cities: Anchorage, Fairbanks, Homer, and Juneau. Only once of these cities – Juneau – is present in the hardest hit region of the state, where the rate of infection for 18-29-year-olds saw a 490% increase from 2011-2015. Of further concern is that no SEP programs are operative in other parts of the state, which means that people in those areas are least likely to receive IDU support services.

The State of Alaska is quick to state that these data should not be considered the final word on HCV infections for 2015; many people who are infected with HCV are not diagnosed until years after the initial infection (Juneau Empire, 2016).

In similar news, Clark County in Indiana has become the sixth county in the state to qualify for permission to open an SEP under a 2015 emergency law that allows states to open an approved exchange if the state’s health commissioner declares a public health emergency in the county (. This was in response to a massive outbreak of HIV and HCV in southern Scott County in late-2014/early-2015 related to IDU.

While Clark County has received approval for the opening of an SEP, it spent a full eight months attempting to work out issues with its initial application. The primary issue, according to County Health Commissioner Kevin Burke, was that state officials didn’t support how the SEP would have been funded. Funding for the program was and will be provided by the Los Angeles-based AIDS Healthcare Foundation (AHF), which has garnered both high praise and sharp criticism in its approach to negotiating contracts with states and counties. After the problematic funding models were hammered out, a second application was submitted and approved.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

References

 

 

 

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